Laparoscopic Cholecystectomy Surgery Steps

Supplies Needed

get a count sheet so Kim can write notes

Back Table

Basin - Lap Choly

Mayo

CLOSING MAYO

OPEN

• Start with back table, using basic pack for lap, check integrity and look for indicators.

• Open basin away from you, push together with back table.

• Instruments - check for indicators changed and locks are intact. Locks in hand when popping. Flip and step back with lid of instrument container, do not flip over tray. Check integrity of the filter. Check inside tray while maintaining distance as well for indicators.

• Next to Open wrapped light tray like a towel back, pull tab out, sides and then flap towards you as you step back. Watch to make sure you are not anywhere near the now open instrument tray.

• Mayo- Open Gown and Gloves

• Surgical Scrub (or Foam In - may need to scrub during actual clinical)

** Nurse will open your remaining supplies to you while you are sterile. Nurse opens on the mayo (green cord, tubing, gown glove, opening sharps on mayo)

• Gown and glove - dance - throwaway trash

SETUP - 20 min, once you grab your gown time starts

* Be mindful of the side your back table that will be closest to the bed. If you are on the patient’s right side of the bed you will want to set up your basin set up on the left. Opposite for the patients left. This allows you to have better reach of tools and close proximity to sharps.

Mayo Stand - ask nurse to open towel pack

• Stand on the long edge facing your back table and tuck right side first this is what the surgeon will see, make it neat - one towel (never two) on mayo tuck four corners.

• Reinforce table with back table drape

• Grab double decker from instrument tray (hands and sleeves need to be up and be careful not to touch the sides of the tray) place on mayo stand - keep hands away from your body. Grab lower section of tray and ASK the circulator to check filters hold away from your body.

• Camera cord tray (on patient bed) - open sides of lid and open - look for indicator, lift and ask for nurse to check the wrap, then place on back table.

announce that moving things to your mayo before the back table helps you avoid contamination and resetting if there is a contaminated tray. You are not able to verify the filters to the second tray to place the double decker on the back table and announce your reasoning. Once you pull out the second part and the tray is confirmed sterile still place the second tray part on the mayo for verification.

Basin - Set up basic contents like normal on the left (do not put handle of pitcher into the kidney bowl) When your basin is empty you will need to refill it in a specific order.

REFILL BASIN ORDER

• suction irrigator - - the nurse will open the package for you, grab it without touching the sides of the package

• insufflation tubing - sterile ghosted by nurse

• camera chord and light cord - Wrap nicely, don’t lift hands too high when wrapping up cords, unwrap one at a time light hands.

• 2 light handles tucked on side

• green cord

• Bovie - tip left visible for count *Edna Lorna Clamp

• Laparoscopic abdominal drape

• 4 towels, 2 side by side

• Surgeons gown, then glove, and then towel for doctor.

Basin is ready and can be moved back to the side of the back table.

BACKTABLE

Ask nurse for 5mm endo-clip & catch (grab out of container)

Left Side - Blue Bowl - Clear Pitcher - Kidney Bowl - Aspeto - Redbook Underneath - Hypo and syringe in Redbook - Sutures underneath - Raytec’s - Medicine Cup in Specimen within medicine cup.

Middle:

Scope tray - Scopes taken out and placed on middle of back table - Instrument Stringer

TROCARS - grab out of wrapped package and put together

• Hassan Trocar - 3 Piece - closed

• EXEL - Snap in place make sure valve is closed

• Veress Step - step parts go together pop in - second part goes on top - closed

• Balloon Trocar - only value that should be open - have syringe for 5 ccs

Fred - 3 Pieces (cap, bottle, and sponge)

MAYO

• Put together trocars

• FRED

• Syringe 5ccs - Balloon Trocar

• Blades

Once countable items are organized ask circulator to count, some steps may be done after count or before depending on speed and process.

FIRST COUNT ITEMS

• Ray-tecs 10

• suture 2

• blade 1

• hypo 1

• Bovie w tip

• Asepto 1

• Fred 3

CONTINUTED STEPS

• Place Instruments in endo tray and take off stringer

• Put Edna towel clamp on Bovie Holster

• Assistants towel, gown, and glove angle it on the scope tray towel-gown- glove

• Mayo - Right Angle Scope - Suction Tip Scope -10mm scope - 2 Alligators - 1 Maryland - Cutdown instruments (closed) - Metz - Straight mayo - 2 Kocher’s - 2 Crile’s - rat tooth forceps or Bonney (fascia) - Knife handle (load blade & on left facing you) - Sharp End of Scopes - Two Raytecs - Hasson S retractors.

Medication - Saline: Before Pour check - Name - Real Expiration date & Warmer Date (Saline can only be in Warmer for 60 Days) amount, label and marker with name and expiration date.

• Label use black side of marker - Sterile Saline NaCl no amount since we can pour more,

• Fill Asepto (should take three times) leave upside down to easier hand to doctor

Now doctor is ready to come in

DOCTOR -

Move basin in front of you - protect field but do not have your back to the back table - towel to dry -introduce yourself - talk to doctor - ask what kind of local they are you using today. Gown + Glove. Don’t forget to spin doctor, they will just walk away

MEDICATION (start with 30 ccs) - nurse will draw up medication, look at name strength amount exp date. Check and ASK if the patient has any allergies

Nurse will pull medication and hold medicine cup for her to put it in.

2 Labels for local (0.5% Marcaine (lidocaine) w epi) 1 on cup 1 on syringe fill syringe to 10ccs - add hypo needle to syringe

DRAPING

Bring Basin to the Bed - 12 in away

Square off incision with towels - Grab 3 towels flip towards you and hand to doctor - Last towel face fold away and drop towel yourself.

drape - pull tape and wrap around with one hand on bottom - same on top - - hand it to the surgeon closed - grab side - left hand hold whole drape - protect right hand and unfold down - for top right hand protect it and right hand - give to nurse or drop if nurse is not ready.

Place thin sheet over patients Skin

Reach over the patient and open side pockets of the drape 2 & 3 leave 1 closed

Chords:

Camera - place near the patients knee cord is fed through in pocket on the surgeons side - red dot on black cord on 12 o’clock (Do not take off piece not sterile inside)

Gray light cord by knee - into pocket hand to nurse (give enough slack to remain sterile)

Insufflation near belly button - untwist chord and place in pocket tuck end in pocket as well

Suction irrigator - tuck blue and red button end into pocket by you - cord reaches to surgeons 3rd pocket in U shape around other cords. Slowly drop battery to floor

Green cord- place plug into pocket on your side - cord will be place and Velcro

Bovie (walk around bed, back to back to surgeon) - clamp edna on drape - take enough slack of bovie cord pull through holster tuck it under and then wrap - clip with clamp and a then continue to throw of green cord with Velcro to secure.

• Move Basin to foot of bed (not really but if asked it contains sterile water)

• Move Mayo Stand (raise height)

• Move Back table to the side of the bed in line with basin to create a corner

Before time out - 6 Things you need to do

1- Attach camera with 10mm scope and light chord - screw in light cord - point it down (bright ass light)

2- Use raytec for white balance. Press W and hold until screen says “W OK”

3- leave raytec

4- Fred - sponge on field, drop solution on sponge put on back table

5 - Attach Suction to Device

6- Right angle to green cord device

NOW READY FOR TIMEOUT - go over information

“ " are callouts that the surgeon or you will say

“LOCAL“- Hand the hypo needle and say the name of local anesthetic (half percent Marcaine with epi) - back on mayo when done

hand blade for incision - bovie cauterize

Dissecting with metz - fat in the way S retractors

Kochers for Fascia 2 ( hold striaght and create space between the bowel and organs - gives space to but in Vicryl suture - hand forceps with ratooth or bonney - Tag and straight Mayo scissors to cut suture

** to switch to left handed suture twist one 180 so it is facing down -

(Crile to tag)

Once done with suture - hand Hasson - ( Vicryl -Tags the fascia and wraps aroung the hasson trocar) Place in Suture Red Box.

“LIGHTS OFF” - nurse shuts lights off before light source is turned on

next create the entry for the trocars repeated step have next thing ready

LOCAL - BLADE - TROCAR

LOCAL ( say medication if a decent time has passed, but not every time)

EXCEL Trocar - green blue alligator -

Balloon Trocar - Need 5cc syringe to fill and remove on balloon trocar going to connect syringe and then withdraw (testing balloon)

Step Trocar - alligator Maryland

Surgery Step for Surgeon (good to know)

looking for cystic duct and cystic artery avoid common bile duct

You will be Transitioning the mayo for the next steps.

2nd MAYO - keep 5 CC - raytec and straight scissors - 2 peans empty 5 cc

refill 10cc hypo keep on backtable since its been used

Endo clip shears catch

First thing to give If switching to an open case:

Laps

Suction and yankeur

blade #10

Choleangiogram - looking for blockages - carm

Contrast IOC intraoperative choleangiogram

Endo clip - then endo clip (clip clip clip cut) - then maryland - looking for cystic artery ( repeat clip, cut) - right angle hot cause it is monoplar (need gorunding pad)

Get rid of scissors on mayo and other endo attachments

Need scopes and switch to 5 mm. big trocar for endo catch to remove gallbladder. Pean to grab bag to pull out gallbladder. (if he cant give me a knife)

bring to backtable - and take out of bag, nurse will come over with container - confirm what the specimin is and drop into container.

CLOSING MAYO -

Skin Suture - 4-0 Monocryl Ps2

Forceps - adson tissue

Hemostat - Crile

Wet and Dry Raytec

Hypo and medicine cup

NEXT STEPS

Use Syringe to suction out balloon trocar

Closing Fascia = closing cavity NEED TO DO A COUNT - leave surgeon scissors - count on the field - then back table. call out at medication at the closing of surgery. Hand suture with forceps - hand scissors to assistant and do final closing skin count.

Can ask for Derma bond once final count is done.

Wet ray tec - dry - derma bond

After Doctor is done, you do not need to stay sterile once there is glue-

Take off Bovie - push table off to the side - ask Crna to have the drape - roll drape hand undereath to lift and roll drape down. Use wet raytec to wipe down. Roll up sheet and gown to make patient decent.

First Responsibility after surgery is the patient. you do not have to remain sterile at this point

Yes wet dry raytec to wipe abdomen if needed. Cover patient to keep decent bottom and top of chest but do not cover over incision area since dermabond is drying.

Then you will need to calculate how much medication was used. Start with 30ML. Take top off of Hypo and measure remaining local in medicine cup and tell nurse what was used. The remaining will be dumped.

Estimated Blood Loss - find the total of how much was used in the bags, containers.

Get Rid of sharps

500 saline total

Full canister is 2100

Bag total 3000

do not have to be sterile after Dermabond

ask crna to hand them the drape

calculate medication used

recap hypo with one hand

inform nurse of ccs medication “We used 21 Cc”

Calculate EBL only if asked

Throw off the sharps

Count sharps and throw into red bucket (hypo, blades, cautery suture)